Stroke (main): Difference between revisions
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==Management== | ==Management== | ||
*Depends on type | |||
**[[Ischemic stroke|Ischemic]] vs [[Hemorrhagic stroke|Hemorrhagic]] | |||
**Acute vs subacute vs old | |||
==Disposition== | ==Disposition== | ||
Revision as of 04:56, 28 September 2015
Stroke Types
Background
- Vascular injury that reduces CBF to specific region of brain causing neuro impairment
- Accurate determination of last known time when pt was at baseline is essential
Ischemic stroke causes (87%)
- Thrombotic (80% of ischemic CVA)
- Atherosclerosis
- Vasculitis
- Vertebral and carotid artery dissection
- Often preceded by yoga, spinal manipulation, coughing, vomiting
- Polycythemia
- Hypercoagulable state (oral contraceptives, antiphospholipid antibodies, protein S and C deficiencies, sickle cell anemia)
- Infection
- Toxicologic exposure (cocaine, amphetamines, etc.)
- Embolic (20% of ischemic CVA)
- Valvular vegetations
- Mural thrombi
- Arterial-arterial emboli from proximal source (ex. amaurosis fugax -> emboli from a proximal carotid artery plaque embolizes to the ophthalmic artery, causing transient monocular blindness)
- Fat emboli
- Septic emboli
- Hypoperfusion
- Cardiac failure resulting in systemic hypotension
- Cryptogenic
- Cryptogenic Stroke (CS) is defined as an Ischemic stroke of obscure or unknown origin. Its causes are unknown. It is transitory or reversible.[1]
Hemorrhagic stroke causes (13%)
- Intracerebral
- Hypertension
- Cerebral amyloid angiopathy (usually found in elderly, tends to be lobar in nature)[2]
- Anticoagulation
- Vascular malformations (e.g. AVM, moyamoya
- Cocaine use
- Subarachnoid hemorrhage
- Berry aneurysm rupture
- Arteriovenous malformation
Clinical Features
Differential Diagnosis
Stroke-like Symptoms
- Stroke
- Seizures/postictal paralysis (Todd paralysis)
- Syncope
- Subdural hemorrhage
- Epidural hemorrhage
- Hypoglycemia
- Hyponatremia
- Meningitis/encephalitis
- Hyperosmotic Coma
- Labyrinthitis
- Drug toxicity
- Bell's Palsy
- Complicated migraine
- Meniere Disease
- Demyelinating disease (MS)
- Conversion disorder
- Transient global amnesia
- Giant cell arteritis
- Cerebral sinus thrombosis
Diagnosis
Stroke Work-Up
- Labs
- POC glucose
- CBC
- Chemistry
- Coags
- Troponin
- T&S
- ECG
- In large ICH or stroke, may see deep TWI and prolong QT, occ ST changes
- Head CT (non-contrast)
- Also consider:
MR Imaging (for Rule-Out CVA or TIA)
- MRI Brain with DWI, ADC (without contrast) AND
- Cervical vascular imaging (ACEP Level B in patients with high short-term risk for stroke):[6]
- MRA brain (without contrast) AND
- MRA neck (without contrast)
- May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA)[7] (ACEP Level C)
Management
- Depends on type
- Ischemic vs Hemorrhagic
- Acute vs subacute vs old
Disposition
- Admit
See Also
- Transient Ischemic Attack (TIA)
- Thrombolysis in Acute Ischemic Stroke (tPA)
- CVA (Post-tPA Hemorrhage)
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage (SAH)
- Cervical Artery Dissection
- NIH Stroke Scale
- Cerebellar Stroke
External Links
References
- ↑ [Finsterer J. Management of cryptogenic stroke. Acta Neurol Belg. 2010 Jun;110(2):135-47. PMID: 20873443].
- ↑ Itoh Y, Yamada M, Hayakawa M, Otomo E, Miyatake T. Cerebral amyloid angiopathy: a significant cause of cerebellar as well as lobar cerebral hemorrhage in the elderly. J Neurol Sci. 1993 Jun;116(2):135-41.
- ↑ Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.
- ↑ Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
- ↑ Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.
- ↑ ACEP Clinical Policy: Suspected Transient Ischemic Attack full text
- ↑ Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.